Healthcare Provider Details

I. General information

NPI: 1114447109
Provider Name (Legal Business Name): JERRY MITCHELL JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19157 CROWLEY EUNICE HWY
CROWLEY LA
70526
US

IV. Provider business mailing address

19157 CROWLEY EUNICE HWY
CROWLEY LA
70526-0801
US

V. Phone/Fax

Practice location:
  • Phone: 337-514-2101
  • Fax: 337-514-2105
Mailing address:
  • Phone: 337-514-2101
  • Fax: 337-514-2105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: